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Background: Primary hyperhidrosis is a condition caused by an excessive stimulation of sweat glands, leading to a decline in both quality of life and social wellbeing. Thoracic sympathectomy surgery provides a relief of the initial symptoms but poses a risk for developing compensatory hyperhidrosis (CH) in various degrees., Objective: The aim of this study was to assess the occurrence and characteristics of CH post-thoracic sympathectomy., Methods: A retrospective cohort study of patients who underwent video-assisted thoracic sympathectomy surgery at level T2-T3 between 2016 and 2022 was conducted. Patients' data were retrieved from medical records and through a telephone interview., Results: A total of 50 patients (32 males and 18 females) were operated on with a mean ± standard deviation (SD) age of 25.9 ± 7.4 years at the time of surgery for palmoplantar hyperhidrosis. Initial symptoms started in childhood at a mean ± SD age of 11.4 ± 3.3 years. Postoperatively, 39 patients (78%) developed CH, more prevalent in males (64.1%) compared to females (35.8%). This CH mainly affected the back and abdomen (100%), followed by the groin and thighs (28.2%), and, to a lesser extent, the craniofacial area (15.3%). Onset of symptoms occurred within 1 week after surgery in 71.7% of cases, with 71.7% reporting mild to moderate symptoms. CH was significantly associated with higher age at the time of surgery, smoking status, and a longer time lapse in the surgery operation (P value < 0.05)., Conclusions: Thoracic sympathectomy is an effective procedure with a high success rate. Despite a relatively higher occurrence of CH, most patients experience milder symptoms and express satisfaction, noting that their expectations were met following the surgery., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To investigate the prevalence of compensatory hyperhidrosis following videothoracic sympathectomy to treat palmoplantar hyperhidrosis and its effect on sweating in the chest, abdomen, back and thighs. Furthermore, to evaluate the concordance between a subjective and an objective method of assessment for compensatory hyperhidrosis., Methods: Forty patients with combined palmar and plantar hyperhidrosis who underwent video-assisted thoracoscopic sympathectomy (15 women and 25 men, with a mean age of 25 years) were prospectively followed for 1 year. Subjective and objective parameters were evaluated, using respectively a questionnaire and a sudorometer (Vapometer)., Results: In the subjective analysis, in the first month, only 10% of patients did not have compensatory hyperhidrosis, and 70% continued to report it at 1 or more sites after 1 year. In the objective analysis, 35% of the patients did not present compensatory hyperhidrosis after 1 month, and this number persisted stable, with 30% of patients remaining free of compensatory hyperhidrosis after 1 year. The most frequent area affected by compensatory hyperhidrosis was the back in both assessments. There was no positive concordance between the results of the objective and subjective analysis at any time in any of the 4 regions studied., Conclusions: Compensatory hyperhidrosis is a very common postoperative side effect after videothoracic sympathectomy, occurring early after the procedure and persisting for prolonged periods of time. The most frequently affected body area is the back, and no concordance between objective and subjective assessments was observed., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Several factors that could influence the efficacy and satisfaction of patients after bilateral thoracic sympathectomy (video-assisted thoracoscopic sympathectomy [VATS]) in the treatment of hyperhidrosis (HH) have been studied, but no studies in the literature have specifically analyzed the effectiveness of treatment and variations in the quality of life of patients aged 40 years or older compared with those of young adult patients (19-40 years)., Methods: We retrospectively analyzed 2,431 HH patients who underwent bilateral VATS and divided the patients into the following groups: a group younger than 40 years old (1,760 patients) and a group 40 years and older (142 patients). Variables included quality of life before surgery, improvement in quality of life after surgery, clinical improvement in sweating, the presence of severe compensatory hyperhidrosis (CH), and general satisfaction at 1 month after surgery., Results: We observed that all surgical patients presented with poor or very poor quality of life before surgery, with similar proportions in both groups. In the postoperative period, we observed improvement in quality of life in more than 90% of the patients, with no significant difference noted between the 2 groups of patients. More than 90% of the patients in this series had great clinical improvement in the main HH site, with no significant difference between the 2 groups. Severe CH occurred in 23.8% of the patients in this series, with no significant difference between the 2 groups., Conclusions: Patients 40 years of age or older benefit just as much as younger patients from VATS performed to treat primary HH, presenting excellent significant surgical results., (Copyright © 2019. Published by Elsevier Inc.)

Background: Primary hyperhidrosis is defined as excessive sweating of idiopathic etiology, associated with sympathetic hyperactivity, which greatly impacts patients' quality of life (QoL). The definitive treatment for palmar and axillary hyperhidrosis (PAH) is video-assisted thoracic sympathectomy (VATS). The objective of this study was to evaluate the quality of life of patients with PAH before and after VATS according to the level of sympathectomy performed, as well as the presence of compensatory hyperhidrosis (CH) and other complications., Methods: All patients who underwent VATS in our vascular surgery department between January 2011 and December 2016 were included in the analysis. From 120 contact attempts, 88 interviews were carried out. Patients were divided into 2 groups according to the intervened thoracic level: high thoracic ganglion (HTG; T2, T2-T3, T2-T3-T4; n = 68) and low thoracic ganglion (LTG; T3, T3-T4, T4; n = 20). The questionnaire evaluated preoperative PAH severity, the presence of CH, preoperative and postoperative QoL, and postoperative satisfaction., Results: The median age of patients was 29 years, and the median follow-up period was 32 months (IQR of 34 months). Most patients had severe or very severe PAH (97.7%) and preoperative QoL was bad or very bad (95.5%). Postoperatively, QoL was significantly improved in all domains evaluated, with no differences observed between the groups. The overall percentage of complications was 11.4%, mostly pneumothorax, but there was a significantly lower incidence of complications in the HTG group (P = 0.029). Compensatory hyperhidrosis developed in 85.2% of cases, but it was only considered intolerable in 10.2%. The incidence of CH was 82.4% in the HTG group and 95% in the LTG group, with no statistically significant differences between the groups (P = 0.147)., Conclusions: Palmar and axillary hyperhidrosis severely affects QoL, and video-assisted thoracic sympathectomy was proven to be effective regardless of the target ganglion resected. Although CH was frequent, it was tolerated in most cases., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The main therapeutic method of treatment for local hyperhidrosis is endoscopic thoracic sympathectomy. Generally, resections of the sympathetic trunk or ganglia are performed between the second rib and sixth rib. However, this procedure can result in compensatory sweating, in which excess sweating occurs on the back, chest, and abdomen. Compensatory sweating has been regarded as a thermoregulatory response and thought to be untreatable. This study suggests that compensatory sweating is not a physiologic reaction and is indeed treatable., Methods: Eight patients with severe compensatory sweating were treated by observing blood perfusion of the skin with laser speckle flowgraphy, which determines the sympathetic nerves related to the area of skin with compensatory sweating. When intraoperative monitoring with laser speckle flowgraphy indicated the position of compensatory sweating by electrical stimulation of the sympathetic ganglion, ganglionectomy was performed., Results: The skin domain that each sympathetic nerve controls was able to be detected by laser speckle flowgraphy. In all patients, compensatory sweating was resolved after interruption of the ganglia or sympathetic nerves related to compensatory sweating., Conclusions: Our results demonstrate that compensatory sweating is caused by denatured sympathetic nerves influenced by endoscopic thoracic sympathectomy and is not the result of a physiological response. With laser speckle flowgraphy, the sympathetic nerve related to the sweating of various parts of the body could be identified. The treatment of compensatory sweating on the back, chest, and stomach was previously considered to be difficult; however, compensatory sweating is demonstrated to be treatable with this technique., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background:  Patients with primary hyperhidrosis present with sweating in two or more sites in nearly 85% of cases. In this study, we examined whether the number of hyperhidrosis sites is related to the surgery outcomes., Methods:  One hundred ninety-three hyperhidrosis patients who underwent bilateral videothoracoscopic sympathectomy after failure or dissatisfaction with clinical treatment were distributed into three groups based on the number of hyperhidrosis sites (one site, two sites, and three or more sites of hyperhidrosis). The primary endpoints in the study were as follows: quality of life prior to surgery, improvement of quality of life after surgery, clinical improvement of sweating, presence or absence of compensatory hyperhidrosis, and general satisfaction after 1 month of surgery., Results:  Patients with two or more hyperhidrosis sites had worse quality of life before surgery than patients with a single hyperhidrosis site. There was an improvement in the quality of life in more than 95% of the patients, clinical improvement in more than 95% of patients, severe compensatory hyperhidrosis in less than 10%, and low general satisfaction after 1 month of surgery in only 2.60% of the patients, with no differences among the three groups., Conclusions:  Patients with more than one preoperative hyperhidrosis site present worse quality of life prior to surgery than those with a single hyperhidrosis site, but the number of hyperhidrosis sites before surgery does not affect surgery outcomes., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Primary hyperhidrosis is a condition that significantly decreases the quality of life (QOL). Thoracic sympathectomy is safe and efficient method of treatment in palmar hyperhidrosis., Objective:  The aim of the study was to evaluate the change in QOL in patients with palmar hyperhidrosis who underwent thoracic sympathectomy., Methods:  The study includes 149 patients (37 men and 112 women) who were treated with bilateral thoracoscopic sympathectomy for primary palmar hyperhidrosis. Subjective and objective evaluation of hyperhidrosis were performed prior to the surgery, 3 and 12 months after the treatment. Control group consists of 305 healthy volunteers (118 men and 187 women). The QOL was measured using Functional Assessment of Chronic Illness Therapy (FACIT) scale., Results:  The average level of palmar hyperhidrosis in the study group prior to surgery was 224.69 ± 179.20 mg/min/m 2 . General QOL (FACIT total) before the surgery was significantly lower in the study group when compared with the control group (66.57 ± 16.33 vs. 91.29 ± 11.13; p  < 0.05). Three months after surgery level of hyperhidrosis decreased significantly and remained at similar level 12 months after the procedure (13.55 ± 15.41 mg/min/m 2 p  < 0.05, respectively). After thoracoscopic sympathectomy, the QOL increased and did not differ when compared with the control group 3 and 12 months after the surgery (90.28 ± 11.13 vs. 91.29 ± 11.13; 2 p  < 0.05, respectively). After thoracoscopic sympathectomy, the QOL increased and did not differ when compared with the control group 3 and 12 months after the surgery (90.28 ± 11.13 vs. 91.29 ± 11.13; p  = 0.55 and 89.59 ± 11.34 vs. 91.29 ± 11.13; p  = 0.84, respectively). The highest increase was observed in functional well-being domain (32.25%); however, it was also noticeable in other domains., Conclusion:  Thoracic sympathectomy is an efficient method of treatment in palmar hyperhidrosis which significantly increases patients' QOL especially in a functional domain., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Video-assisted thoracoscopic surgery (VATS) clipping of the sympathetic branch has become the standard approach for the treatment of essential hyperhidrosis when conservative treatment failed. However, this is associated with relevant potential complications such as postoperative compensatory sweating and recurrent sweating. We report the outcome after selective sympathectomy (ramicotomy) through a miniuniportal VATS approach in patients with therapy-refractory palmar and/or axillary hyperhidrosis., Methods:  A total of 51 consecutive patients (37 females, mean age: 30 years, range: 12-64 years) who suffered from therapy-refractory palmar and/or axillary severe hyperhidrosis were included. Data were prospectively collected and retrospectively analyzed. All patients underwent bilateral miniuniportal VATS ramicotomy. Duration of surgery, hospital stay, recurrent, and compensatory sweating were documented., Results:  All patients had palmar sweating, where 51% had additional axillary sweating and 57% had additional plantar sweating. In all patients, selective division of the rami communicantes of the thoracic sympathetic ganglions Th2 to Th5 was performed. The mean duration of bilateral surgery for both sides was 67 ± 2.5 minutes. The mean postoperative hospital stay was 2 ± 1 days. After surgery and at further follow-up (mean: 12 ± 2.5 months), all patients presented dry and warm hands and axillae, without any evidence of compensatory or recurrent sweating. All patients described a remarkable increase in quality of life., Conclusion:  Miniuniportal VATS ramicotomy represents a feasible surgical technique with a very high success and satisfaction rate. Therefore, this approach should be considered as the method of choice for the treatment of patients with severe therapy-refractory palmar and axillary hyperhidrosis., Competing Interests: None to be declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Primary palmar hyperhidrosis (PPH) is featured by aberrantly perspiration of the hands, which may bring a lot of inconvenience to patient's daily life and work. The purpose of this study is to summarize the clinical effect of needlescopic video-assisted thoracic bilateral T4 sympathicotomy for the treatment of PPH., Patients and Methods:  Between January 2009 and March 2014, 200 patients received needlescopic video-assisted thoracic bilateral T4 sympathicotomy. We, respectively, took two 5-mm incisions in the third intercostal space on the anterior axillary line and in the fifth intercostal space on the middle axillary line. After collapsing left lung, needlescopic exploration was the first step to determine the targeted sympathetic chain through the third intercostal space. Electric coagulation hook was inserted from another port to cut T4 sympathetic chain and the bypassing nerve fibers for 2 to 3 cm along the surface of the fourth rib. Right thoracic cavity was also administered the same procedure. The palmar temperature was recorded before and after sympathicotomy. The symptom improvement, operative complications, patients' recovery, and satisfaction were evaluated., Finding:  One hundred and ninety-seven patients uneventfully received two 5-mm port bilateral sympathicotomy, and another 3 patients with extensive pleural adhesions completed the surgery through enlarging the third intercostal incision to 2 cm without conversion to open surgery. All operative procedures were completed in 15 to 35 minutes. The hospital stay was 2 to 4 days. The palmar temperature increased by 2.0 ± 0.5°C, and hyperhidrosis immediately disappeared in both hands after surgery. The efficacy rate was 100%. The postoperative complications such as hemorrhage, hemopneumothorax, bradycardia, or Horner's syndrome had no occurrence. During 6 to 60 months follow-up, mild compensatory sweating of buttock, back, and thigh occurred in 30 patients (15%) at 2 to 5 days after surgery and gradually disappeared at postoperative 15 to 30 days or longer time. All patients were greatly satisfied with the effect with better confidence and quality of life. Until now, no recurrent palmar hyperhidrosis happened., Conclusion:  Needlescopic video-assisted thoracic bilateral T4 sympathicotomy could reach an excellent and immediate result of treating PPH. It is a safe, convenient, and minimally invasive method appropriate for wide clinical use., Competing Interests: The authors report no conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To conduct a longitudinal investigation of cardiac vagal activity (CVA) by measuring resting HR and calculating the cardiac vagal index (CVI) in individuals undergoing sympathectomy for the treatment of primary hyperhidrosis., Methods: This was a descriptive longitudinal study involving 22 patients, 13 of whom were female. The mean age was 22.5 ± 8.8 years. The palms, soles, and axillae were the most commonly affected sites. Resting HR was measured by an electrocardiogram performed 20 min before the 4-second exercise test (4sET), which was used in order to evaluate CVA at three different time points: before surgery, one month after surgery, and four years after surgery., Results: Resting HR (expressed as mean ± SE) was found to have decreased significantly at 1 month after surgery (73.1 ± 1.6 bpm before surgery vs. 69.7 ± 1.2 bpm at one month after surgery; p = 0.01). However, the HR values obtained at four years after surgery tended to be similar to those obtained before surgery (p = 0.31). The CVI (expressed as mean ± SE) was found to have increased significantly at one month after surgery (1.44 ± 0.04 before surgery vs. 1.53 ± 0.03 at one month after surgery; p = 0.02). However, the CVI obtained at four years after surgery tended to be similar to that obtained before surgery (p = 0.10)., Conclusions: At one month after sympathectomy for primary hyperhidrosis, patients present with changes in resting HR and CVA, both of which tend to return to baseline at four years after surgery.

Background: Endoscopic thoracic sympathectomy (ETS) is the gold standard treatment for primary hyperhidrosis, with excellent short-term results. The potential for adverse effects, particularly compensatory sweating (CS), may affect long-term satisfaction. In this retrospective review we aimed to examine long-term results and quality of life (QOL) after ETS in the management of primary, dominantly palmar, hyperhidrosis from a single institution., Methods: A review of patients who had undergone ETS for primary palmar or axillary hyperhidrosis between February 2004 and May 2015 was performed. Utilizing a modified questionnaire with validated components, patients were contacted to obtain responses designed to measure outcomes and QOL domains., Results: Of the 96 eligible patients, 58 (60%) consented and completed the questionnaire. The median time of survey from surgery was 60 months (interquartile range, 35 to 122 months). Increased QOL was reported in 84% (49 of 58) of patients, and increased ability to perform tasks in 86% (50 of 58). Satisfaction was identified in 97% (56 of 58) of patients, and 93% (54 of 58) reported that they would recommend the procedure. CS was reported in 84% (49 of 58), ranging from minor in 78% (38 of 49) to severe in 22% (11 of 49). There were 146 total CS areas involved, most commonly the back (78%, 38 of 49). One ETS reversal, for extreme CS, was performed. Nonetheless, 78% (38 of 49) reported CS to be less disruptive than preoperative hyperhidrosis., Conclusions: This study confirms that the benefits of ETS are maintained in the long term. Although CS is the main cause for discontent postoperatively, it is still preferred over the distress experienced from palmar or axillary hyperhidrosis and QOL is increased despite CS., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There are different techniques for thoracoscopic sympathectomy for management of primary hyperhidrosis. Each technique has the advantage of giving good surgical results, but may cause complications, which depend on the level of sympathectomy used in each technique., Methods: From October 2012 to August 2016, a total number of 120 patients (of primary palmar and axillary hyperhidrosis) were enrolled in this prospective randomized study. Patients were randomized preoperatively and divided into 2 groups: group A (underwent T2, T3, and T4 sympathectomy) and group B (underwent T3 and T4 sympathectomy) with 1 year of follow-up. Improvement of palm sweating, development of complications, patient satisfaction, and quality of life were evaluated., Results: Family history was positive in 33 patients (55%) in group A and in 31 patients (52%) in group B. All patients had improvement of hand sweating. Overdry hands were significant in group A (p = 0.032). Compensatory sweating was significant in group A after the first month (p = 0.016), after 6 months (p = 0.022), and after 12 months (p = 0.025). In group B, very satisfied patients were significant after 6 and 12 months (p = 0.002 and 0.000, respectively)., Conclusions: Limited sympathectomy to the level of T3 and T4 has the same therapeutic effect obtained by T2, T3, and T4 sympathectomy with less complications, greater patient satisfaction, and better quality of life. It should be the technique of choice for treatment of primary palmar and axillary hyperhidrosis., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Several factors may potentially influence the efficacy and patient satisfaction after bilateral thoracic sympathectomy as the treatment for hyperhidrosis, but few studies have specifically analyzed the impact of age on the efficacy of this treatment, the occurrence of compensatory hyperhidrosis (CH), and variations in the quality of life., Methods: We retrospectively analyzed the effect of age, body mass index, surgical techniques, quality of life before surgery, betterment in the quality of life after surgery, clinical improvement in sweating at the main site, and the occurrence and intensity of CH in patients with hyperhidrosis (n = 1633) who underwent bilateral sympathectomy., Results: Quality of life improved in more than 90% of patients, and severe CH occurred in 5.4%. Age did not affect these outcomes. The older, the greater reduction in sweating, and CH was linked to other variables (body mass index, craniofacial hyperhidrosis, and level of resection)., Conclusions: We observed that patients with old age reported an improvement in sweating in the main site of hyperhidrosis. Sympathectomy outcomes in older patients are similar to those observed in younger patients in terms of quality of life improvement and occurrence of CH., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The impact of upper thoracic percutaneous sympathectomy with radiofrequency on the quality of life (QOL) of patients with palmar hyperhidrosis was evaluated. Thirty-six patients with palmar hyperhidrosis were selected for a prospective observational study. Treatment consisted of percutaneous radiofrequency thoracic sympathectomy of T3 and T4 ganglions in all cases. QOL questionnaires were applied preoperatively, on the 1st postoperative (PO) day, and on the 30th, 90th, 180th, and 360th PO days. Furthermore, compensatory hyperhidrosis (HDSSc) scale measures were used simultaneously, in order to evaluate the rate and frequency of this side effect. The QOL questionnaire evaluation showed preoperative values of 83.94 ± 4.74 (meaning poor quality of life), decreasing to 24.61 ± 2.86 on the 1st PO day, 25.14 ± 3.12 on the 30th PO day, 31.28 ± 4.42 on the 90th PO day, 32.97 ± 4.54 on the 180th PO day, and 33.94 ± 4.6 on the 360th PO day (all postoperative results with values below 35 were considered optimal). Compensatory hyperhidrosis (HDSSc) scale values were 1.14 ± 0.35 on the 1st PO day, 1.42 ± 0.55 on the 30th PO day, 1.83 ± 0.85 on the 90th PO day, 1.92 ± 0.91 on the 180th PO day, and 1.92 ± 0.91 on the 360th PO day (meaning that hyperhidrosis was mainly unnoticed). Patients' subjective satisfaction was considered very good and the majority of patients would recommend the treatment procedure. Percutaneous radiofrequency thoracic sympathectomy had a positive impact on the quality of life of patients with palmar hyperhidrosis, compared to the surgical treatment, with a low rate and intensity of HDSSc and without other complications., (Copyright © 2018. Published by Elsevier Inc.)

Introduction: Facial hyperhidrosis (FH) may lead patients to a significantly impaired quality of life (QOL). Video-assisted thoracoscopic sympathectomy (VATS) is reserved for more severe cases refractory to common first-line agents. The aim of this study was to evaluate the efficacy of VATS for FH and to compare the results between patients with facial hyperhidrosis as main complaint (FHMC) and patients with facial hyperhidrosis as nonmain complaint (FHNMC)., Methods: This was a retrospective study based on medical chart analysis from March 2000 to January 2014: 40 patients with FHMC and 136 patients with FHNMC. Patients underwent VATS at the T2, T3, or T4 level, according to the main site of complaint. We assessed improvement in QOL, improvement in hyperhidrosis, and presence of complications and side effects, notably compensatory hyperhidrosis (CH)., Results: Patients with FHMC reported greater improvement in FH (97.1% versus 93.6%; P = 0.006) but had lower improvement in QOL (78.2% versus 92.7%; P = 0.024) compared to patients with FHNMC. For patients with FHNMC, any degree of improvement in FH was reported by 100%, almost 95%, and nearly 80% of the patients who underwent VATS at the T2, T3, and T4 level, respectively (P = 0.039). Pain and CH were reported by more than 61% and 92% of the patients, respectively, with no statistical difference between both groups., Conclusions: Patients with FHMC, despite the greater improvement in FH, experienced lower improvement in QOL compared to patients with FHNMC. CH was the most frequent side effect in both groups, affecting more than 92% of the patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to assess the reduction in quality of life (QoL) caused by the persistence of primary plantar hyperhidrosis (PPH) symptoms and the level of satisfaction in PPH patients after retroperitoneoscopic lumbar sympathectomy (RLS). The efficacy, safety, and procedure of bilateral RLS in both sexes are also described in this study., Methods: This is a longitudinal study of consecutive patients who sought specific treatment from a private practitioner for severe PPH as classified on the Hyperhidrosis Disease Severity Scale (HDSS) from October 2005 to October 2014. The patients were asked to report the symptoms of PPH experienced in the immediate preoperative period and to complete a standardized QoL questionnaire developed by de Campos at least 12 months after RLS. Disease outcomes, recurrence of symptoms, and any adverse effects of surgery were evaluated after 30 days and at least 12 months after RLS., Results: Lumbar sympathectomy was performed 116 times in 58 patients; 30 days after surgery, PPH was resolved in all patients. Three patients (5.2%) reported transient thigh neuralgia, and 19 (32.7%) reported transient paresthesia in the lower limbs. There were no reports of retrograde ejaculation. At a minimum of 12 months after RLS, 49 of the 58 patients had fully and correctly answered the follow-up questionnaire and noted a mild (HDSS 2) to moderate (HDSS 3) increase in pre-existing compensatory sweating. One patient had a PPH relapse within 6 months. Improvement in QoL due to the resolution of PPH was reported in 98% of the 49 patients. None of the operations necessitated a change in the laparotomy approach, and none of the patients died., Conclusions: RLS is safe and effective for the treatment of severe PPH in both sexes. There were no reports of retrograde ejaculation after resection of L3 and L4 ganglia. There was a mild to moderate increase in compensatory sweating in about half of the patients, but without any regret or dissatisfaction for having undergone the surgery because of a significant improvement in QoL., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background  Thoracic sympathectomy (TS) is one of the most effective methods of treatment of primary hyperhidrosis. One of the side effects of this procedure is compensatory sweating (CS). Objective  The aim of our study was to evaluate the influence of body mass index (BMI) on CS in patients after TS due to palmar hyperhidrosis. Methods  Data from 157 patients with palmar hyperhidrosis who underwent TS were collected. The patients were subsequently divided in two groups according to their initial BMI: group A, BMI < 25 kg/m 2 , and group B, BMI ≥ 25 kg/m 2 . Objective (gravimetry) and subjective (VAS) measurements of the intensity of hyperhidrosis were taken from the patients' bodies prior to surgery, as well as 3 and 12 months after TS. Results  Average palmar hyperhidrosis levels before the surgery did not differ significantly between the two groups (238.65 vs. 190.15; p  = 0.053). A statistically significant decrease in palmar hyperhidrosis was noted in both groups, both 3 and 12 months after surgery (238.65 vs. 11.86 vs. 13.5; p  < 0.05, and 190.15 vs. 16.67 vs. 11.81; p  < 0.05, respectively). The intensity of sweating over the abdomino-lumbar area differed significantly between the groups before the surgery, both in subjective (1.71 vs. 3.61; p  < 0.05) and objective (13.57 vs. 35.95; p  < 0.05) evaluations. Three months after surgical intervention, an intensification of CS was observed in both the groups; however, no statistically significant differences were observed between the two sets of patients (VAS: 4.58 vs. 5.16; p  = 0.38; gravimetry: 33.87 vs. 53.89; p  = 0.12). Twelve months after TS, CS was higher in the group with an initial BMI ≥ 25 kg/m 2 , both in subjective and objective evaluations (3.23 vs. 4.94; p  = 0.03 and 18.08 vs. 80.21; p  = 0.026, respectively). Conclusion  Patients with a BMI ≥ 25 kg/m 2 experience more severe CS after TS, both in subjective and objective evaluations., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Hyperhidrosis is a dysfunction of the autonomic nervous system that results in regional excessive sweating, mostly in the hands, armpits, and feet. A permanent and effective treatment of hyperhidrosis can be achieved by interruption of the thoracic sympathetic chain with endoscopic thoracic sympathectomy (ETS). However, some side effects, particularly compensatory sweating (CS), are the limitations of this procedure. The mechanism of CS and the associated risk factors are still controversial. The aim of this retrospective study was to determine the relationship with various parameters associated with CS in patients undergoing ETS. Materials and Methods  ETS was performed on a total of 95 patients for palmar hyperhidrosis, axillary hyperhidrosis and facial blushing by the same surgeon. The mean age of the patients was 26.41 (± 7) years, and 54 (56.8%) were males. Palmar hyperhidrosis was present in 54 (56.8%) patients, axillary hyperhidrosis in 33 (34.7%) patients, and facial blushing in 8 (8.5%) patients. Moreover, 38 (40%) patients also had plantar sweating. The severity of CS was rated into three scales as less, moderate, and severe. Results  Regarding the severity of CS, 55 (57.9%) patients had no or less CS, 28 (29.5%) had moderate CS, and 12 (12.6%) patients had severe CS. Higher age group had a significant increased risk of severe CS ( p  = 0.03) ( r  = 0.262). Patients with body mass index (BMI) > 25 kg/m 2 had a statistically significantly increased risk of severe CS ( p  = 0.016). Facial blushing resulted in severe CS in a significantly higher proportion of patients than by palmar and axillary hyperhidrosis ( p  = 0.001). The level of surgery was another important risk factor for CS, with the T2 level showing an increased risk of severe CS compared with T3 level ( p  < 0.001). Furthermore, plantar sweating was inversely and significantly related to the development of CS. Patients with plantar sweating had a significantly decreased incidence of developing CS ( p  = 0.015). Conclusion  CS after thoracic sympathectomy for primary hyperhidrosis is the most displeasing and restrictive side effect. This study demonstrates that older age, operation level, facial blushing, and high BMI are risk factors for CS, as have been shown in several similar studies. An interesting finding of the present study is that there was a decreased incidence of CS among patients with plantar sweating. This situation may help us to distinguish high risk for CS before ETS operation., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Thoracoscopic sympathectomy (TS) was the preferred surgical treatment for palmar hyperhidrosis (PH), but postoperative complications such as compensatory sweating (CS) were common. This study was projected to compare R3 versus R4 TS for treating severe PH. Methods  From April 2009 and March 2015, 106 consecutive patients with severe PH underwent bilateral R3 ( n  = 62) or R4 ( n  = 44) TS at The Second Affiliated Hospital of Nanchang University. The patients were followed up to evaluate symptom resolution, postoperative complications, satisfaction level, and severity of CS. Results  The 106 patients underwent 212 sympathecotomies and were cured with no severe complications or perioperative mortality. The incidence of minor side effects (such as pneumothorax, gustatory sweating, moist hands, and bradycardia) was similar in both groups. More patients had overdry hands in the R3 group than in the R4 group (6/62 vs. 0/44; p  = 0.040). More CS occurred in the R3 group as compared with the R4 group (42/62 vs. 23/44; p  = 0.156). The incidence of moderate-to-severe CS was higher in the R3 group than in the R4 group (14/62 vs. 4/40; p  = 0.045). Most patients were satisfied with the results, except for three (5.84%) in the R3 group and one (2.27%) in the R4 group. Conclusion  PH can be effectively treated by either R3 or R4 TS, with high rates of patient satisfaction. R4 sympathectomy appears to be associated with less severe CS and should be the choice of denervation level., Competing Interests: Conflict of Interest: Wenxiong Zhang, Yiping Wei, Han Jiang, Jianjun Xu, and Dongliang Yu have no conflicts of interest or financial ties to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Endoscopic thoracic sympathectomy (ETS) is an effective treatment for primary hyperhidrosis. However, compensatory sweating (CS) may occur in many patients. Sympathetic nerve reconstruction (SNR) can be used to counteract severe CS, but the studies on the effects of SNR are few. Patients and Methods  Nineteen out of 150 SNR patients were contacted by employing a long-term questionnaire. In this questionnaire, different kinds of sweating were evaluated using a four-graded symptom analysis and the visual analog scale before ETS, after ETS, and after SNR. Results  The mean age of the 16 male and 3 female patients at the SNR was 32 years. The mean follow-up was 87 months. According to the long-term questionnaire, the benefit was either excellent (4 patients, 21%), good (3 patients, 15.8%), or reasonable (7 patients, 36.8%) in 14 patients (73.8%), while the benefit was questionable in 1 patient (5.3%). For three patients (15.8%), no benefit was found, and in one patient (5.3%), the situation had deteriorated. Conclusions  Improvement in the side effects of ETS after SNR was found in nearly 75% of the patients. This indicates that SNR can be considered as an alternative treatment for patients with severe CS after ETS that is unresponsive to conservative treatment., Competing Interests: Disclosure: The authors have no conflict of interest or financial ties to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Videothoracoscopy sympathectomy (VATS) is the only definitive treatment for primary hyperhidrosis (HH). Since 2007, in our institution, patients with HH were initially treated with oxybutynin chloride to avoid VATS and reduce compensatory hyperhidrosis incidence with good results. The aim of this study was to analyze the surgical response of patients suffering from essential hyperhidrosis after failure of oxybutynin chloride treatment., Methods: This was an observational retrospective study that included 737 patients who were diagnosed with palmar or axillary hyperhidrosis and received VATS from January 2007 to January 2014. Patients were selected for 2 different groups: The post-oxybutynin surgery group consisted of 167 patients that were initially treated with oxybutynin chloride for 6 weeks and then received VATS after drug treatment failure. The primary surgery group consisted of a historic control group of 570 patients who were referred directly to surgical treatment. We evaluated the degree of improvement in symptoms 30 days after surgery and quality of life before and after the surgical treatment., Results: All patients showed poor or very poor quality of life before surgery. Most patients showed a response between moderate and high after surgical treatment. However, those in primary surgery group responded better (95.1% vs. 98.2%). In the quality of life after surgery, most of the patients reported improvement, and the primary surgery group had better improvement (92.2% vs. 95.1%)., Conclusions: VATS showed good results in patients with palmar or axillary hyperhidrosis regarding surgical response and improvement on quality of life even when the previous oxybutynin chloride treatment failed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Compensatory hyperhidrosis (HH) is the most common and feared side effect of thoracic sympathectomy, because patients with severe forms have their quality of life greatly impaired. The most well-known factors associated with compensatory HH are extension of manipulation of the sympathetic chain, level of sympathetic denervation, and body mass index. Technical developments as well as the proper selection of patients for surgery have been crucial in reducing the occurrence of severe forms of compensatory HH. Therapeutic options include topical agents, botulinum toxin, systemic anticholinergics, clip removal, and sympathetic chain reconstruction, although the efficacy is not well-established for all the methods., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Primary hyperhidrosis interferes with social activities and requires an effective and safe treatment. We aimed to compare the therapeutic outcomes of unilateral single-port sympathicotomy and open surgery., Methods: Forty patients with primary palmar hyperhidrosis underwent sympathicotomy; 20 had open surgery, and 20 had video-assisted thoracic surgery. Complete resection of the T1 to T4 ganglia was performed by open surgery, and cutting and cauterization of the sympathetic chain between the T2 and T3 ganglia in the dominant hand was undertaken using video-assisted thoracic surgery. The patients were followed up at 1, 3, 6, and 12 months after surgery., Results: The mean operative times were 39.6 ± 1.46 and 79.8 ± 1.53 min in the video-assisted thoracic surgery and open surgery group, respectively. The mean hospitalization was 2.2 ± 0.41 days after video-assisted thoracic surgery and 3.3 ± 0.47 days after open surgery. Complications included delayed hemothorax, compensatory hyperhidrosis, and wound infection. The mean blood loss during surgery and time to return to work were significantly less in the video-assisted thoracic surgery group. Excessive sweating was completely alleviated in the dominant hand in all patients, and in the opposite hand in 60% and 65% of the video-assisted thoracic surgery and open surgery group, respectively., Conclusion: Single-port sympathicotomy between the T2 and T3 ganglia ipsilateral to the dominant hand is a safe, minimally invasive, and effective treatment for primary palmar hyperhidrosis. Alleviation of excessive sweating in the opposite hand can also be achieved in a large proportion of these patients., (© The Author(s) 2016.)

Background: Hyperhidrosis is secondary to over activation of the sympathetic nervous system and surgical sympathectomy is the treatment of choice when other modalities have failed. This study investigated anatomic variation in the upper thoracic sympathetic chain and associated rami communicantes among cadaveric specimens. It considers the implications of these findings on surgical techniques to treat hyperhidrosis., Methods: The upper 4 thoracic sympathetic ganglia, intercostal nerves, and connecting rami were dissected, measured and mapped in 40 sides of 20 adult human cadavers. Ganglia location was recorded. The incidence, orientation, and distance travelled by rami communicantes was compared across different ganglionic levels and between sides., Results: The percentage of ganglia located below their associated intercostal space was 6.25% with stellate ganglions present in 70% of specimens and Kuntz fibers noted in 40%. There was a stepwise reduction in incidence of rami from superior to inferior placed ganglia. The number of rami identified across all levels was significantly greater on the right (P = 0.03). The horizontal distance between the sympathetic chain and union of the rami on the intercostal nerves was significantly greater on the right across all levels (P = 0.04)., Conclusions: There was substantial variation in the rami communicantes across the upper 4 ganglia and between right and left sides. Consideration of this variation should be given when planning surgical sympathectomy for hyperhidrosis particularly to avoid symptom recurrence., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Primary focal hyperhidrosis is a disease of unknown cause with profuse perspiration of local sites (head, face, palms, soles of feet, and axillae) that adversely affects daily life. Guidelines have been proposed in the USA [1], Canada [2], and Japan [3]. The symptoms impair quality of life, with significant negative effects on daily existence and personal relationships. The current goal in medical practice for patients with hyperhidrosis is to provide guidance and encourage coping skills for a normal daily life, as well as give appropriate advice regarding treatment options. On occasion, in order to improve quality of life, it is necessary to recommend surgical therapy when conservative treatment fails; this requires an understanding of the mechanisms of available treatments and their effects. This paper reviews theories of primary focal hyperhidrosis with regard to pathology, epidemiology, and treatment., (© 2016 S. Karger AG, Basel.)

Objective: Natural orifice transluminal endoscopic surgery (NOTES) has recently become a hot spot in the field of minimally invasive surgery. But, most of the procedures are still in the early stages of development and limited to animal experiments. Transareolar endoscopic surgery could work as a viable intermediate step before thoracic NOTES. Under intravenous anesthesia without endotracheal intubation, transareolar endoscopic thoracic sympathectomy (ETS) with a flexible endoscope has rarely been attempted. The objective of this study is to evaluate the feasibility and safety of this novel minimally invasive technique in managing primary palmar hyperhidrosis (PPH)., Methods: From June 2012 to July 2014, a total of 58 male patients with severe PPH underwent transareolar ETS by use of a flexible endoscope. Under intravenous anesthesia without endotracheal intubation, a flexible endoscope was introduced through the incision on the edge of the areola into the thoracic cavity. The thoracic sympathetic chain was ablated at the level of the fourth rib., Results: All procedures were successfully performed with a mean operating time of 33.6 ± 8.3 min. All patients regained consciousness rapidly and none of them complained about sore throat after surgery. There were no operative mortality and conversion to open procedure. The symptoms of all patients disappeared as soon as the sympathetic chain was cut off. Fifty six patients (96.6%) were discharged from the hospital on the first postoperative day. The postoperative complications were minor, and no patients developed Horner's syndrome. At 3 months postoperatively, there was no obvious surgical scar on the chest wall, and none of the patients complained about postoperative pain. Compensatory hyperhidrosis (CH) appeared in 19 patients. No recurrent symptoms were observed in our study. One year follow-up revealed an excellent cosmetic result and degree of satisfaction., Conclusion: Nonintubated transareolar ETS with a flexible endoscope is a safe, effective and minimally invasive therapeutic procedure, which has the possible advantages of thoracic NOTES and can be performed in routine clinical practice for male PPH patients.

Objective: The objective of this study was to evaluate and compare thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction., Materials and Methods: Two groups of patient underwent T3 thoracoscopic sympathectomy and thoracoscopic sympathicotomy under general anesthesia using single-lung ventilation via a double-lumen endotracheal tube by the same surgical team for the treatment of severe primary palmar hyperhidrosis or a combination of levels for multiarea between 2008 and 2013. The groups were homogeneous for relevant demographic, physiological, and clinical data. All patients were examined preoperatively and were followed up at 6 months postoperatively. In both groups, patient's satisfaction was evaluated 6 months after surgery by a detailed interview and scored into three grades (1 = very satisfied, 2 = satisfied, and 3 = dissatisfied)., Results: No operative mortality, major intraoperative complication, infections, and Horner syndrome were recorded. There was no treatment failure. The average time of operation was 50 minutes for Group A (sympathectomy) and 36 minutes for Group B (sympathicotomy). Compensatory sweating occurred in 40 patients (89% for Group A and 85.11% for Group B) with a different accumulation of the severity degree. The satisfaction rate was 91.11% for Group A and 93.61% for Group B., Conclusion: There was no significant difference between thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. Neither surgical technique is better than the other one for palmar hyperhidrosis treatment. Development of severe compensatory sweating and postoperative pain are major determinant factors of patient dissatisfaction. Sympathicotomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn., (Georg Thieme Verlag KG Stuttgart · New York.)

Background and Objective: Primary palmar hyperhidrosis that arises mostly during puberty and early adolescence has a tremendous impact on the quality of life in patients. This study aimed to investigate the effectiveness of unilateral video-assisted thoracic sympathectomy for dominant hand in these patients., Patients and Methods: From July 2010 to June 2013, 52 patients with primary palmar hyperhidrosis underwent unilateral video-assisted thoracoscopic sympathectomy for dominant hand. We analyzed the outcomes regarding the resolution of symptoms, occurrence of complications, recurrence rate, and compensatory hyperhidrosis, and need of operation for opposite side., Findings: All patients were followed up from 6 to 42 months. Palmar hyperhidrosis was completely alleviated and absolute dryness was achieved in all patients at the same hand after the operation. Palmar hyperhidrosis in the opposite hand was cured to a complete dryness in 24 (46.15%) patients. No change happened in the opposite hand in 22 (42.3%) patients, but an increase was seen in 6 (11.53%) patients. Only seven (13.46%) patients needed to undergo contralateral sympathectomy. Compensatory hyperhidrosis occurred in 13 patients (25%) after unilateral sympathectomy. Another five patients (totally 18, 34.6%) were involved with compensatory hyperhidrosis after contralateral sympathectomy. It was mainly on the trunk in all 18 patients., Conclusion: Unilateral dominant side thoracoscopic sympathectomy for patients with primary palmar hyperhidrosis is an effective, safe, and minimally invasive procedure. Only a small number of patients will eventually require a contralateral sympathectomy in nondominant hand., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The aim of the study was to evaluate the sympathectomy procedures for primary hyperhidrosis in terms of complications and effectiveness., Methods: From January 2010 to September 2012 we performed 130 sympathectomies in 65 patients, 27 males (42%) and 38 females (58%). Electrocoagulation was used in 20 procedures (15%), ultrasonic scalpel in 54 (42%), and radiofrequency dissector in 56 (43%). Seven patients (11%) underwent bilateral sympathectomy in the same surgical session, while in 58 (89%) the right surgical approach was delayed 30 days from the first procedure., Results: We noticed 12 complications (9%): (a) chest pain in 6 patients (4 with electrocoagulation, 1 with ultrasonic scalpel, and 1 with radiofrequency dissector), which disappeared in 20 ± 1 day; (b) paresthesias in 3 electrocoagulation patients, was solved in 23 ± 5 days; (c) bradycardia in 1 ultrasonic patient, normalized in 4th postoperative hour; (d) unilateral relapse in 2 electrocoagulation patients after the second side approach, positively treated in 1 patient by resurgery in video-assisted thoracoscopy (VAT). The quality-adjusted life year and the quality of life evaluation revealed a statistically significant improvement (p = 0.02) in excessive sweating and general satisfaction after surgery, with Ultracision and LigaSure showing better findings than electrocoagulation., Conclusion: The latest generation devices offered greater efficacy in the treatment of hyperhidrosis, minimizing complications and facilitating the resumption of normal work and social activity of patients., (Georg Thieme Verlag KG Stuttgart · New York.)

We describe the first case of severe palmar hyperhidrosis treated with single-incision subxiphoid thoracoscopic ablative sympathectomy, bilaterally, at T3 level. The single-incision subxiphoid thoracoscopic approach required only a 2-cm incision in the upper abdomen. In addition, the technique does not cause postoperative intercostal neuropathy and postoperative pain is minimal as the intercostal space is bypassed. Total operative time was ∼60 min and the volume of blood loss was 10 ml. The patient was discharged from the hospital the next day with complete remission of her symptoms. Excess palmar sweating released after operation and there was no compensatory sweating after a 6-month follow-up., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To compare compensatory sweating after lowering or restricting the level of sympathectomy., Method: A systematic review and meta-analysis were conducted of all randomized controlled trials published in English that compared compensatory sweating after lowering or restricting the level of sympathectomy. The Cochrane collaboration tool was used to assess the risk of bias, and the Mantel-Haenszel odds ratio method was used for the meta-analysis., Results: A total of 11 randomized controlled trials were included, including a total of 1079 patients. Five of the randomized controlled trials studied restricting the level of sympathectomy, and the remaining six studied lowering the level of sympathectomy., Conclusions: The compiled randomized controlled trial results published so far in the literature do not support the claims that lowering or restricting the level of sympathetic ablation results in less compensatory sweating.

Background/aim: The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing., Materials and Methods: We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during controlled apnea periods., Results: Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating. No recurrence was observed during the follow-up period., Conclusion: Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts.

Objective: Compensatory hyperhidrosis is a common devastating adverse effect after endoscopic thoracic sympathectomy for patients undergoing surgical treatment of primary hyperhidrosis. We sought to determine whether a correlation existed in our patient population between the level and extent of sympathetic chain resection and the subsequent development of compensatory hyperhidrosis., Methods: All patients undergoing endoscopic thoracic sympathectomy in the T2-T3, T2-T4, T2-T5, or T2-T6 levels for palmar or axillary hyperhidrosis at the University of Iowa Hospital and Clinics (n = 97) from January 2004 to January 2013 were retrospectively reviewed., Results: Differences in the preoperative patient characteristics were not statistically significant among the patients receiving T2-T3, T2-T4, T2-T5, or T2-T6 level resections. Of the 97 included patients, 28 (29%) experienced transient compensatory hyperhidrosis and 4 (4%) complained of severe compensatory hyperhidrosis and required additional treatment. No operative mortalities occurred, and the morbidity was similar among the groups., Conclusions: Most patients had successful outcomes after undergoing extensive resection without changes in the incidence of compensatory hyperhidrosis. Therefore, we recommend performing complete and adequate resection for relief of symptoms in patients with primary hyperhidrosis., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of this study is to evaluate the impact of transthoracic endoscopic sympathectomy on plantar hyperhidrosis in patients operated on for upper limb hyperhidrosis., Materials and Methods: From 2003 to 2011, 41 consecutive patients underwent videothoracoscopic T3-T4 sympathicotomy or T3-T4 ganglion block at our Unit for upper limb hyperhidrosis. Twenty-one (51%) were affected by palmar hyperhidrosis and 20 (49%) by palmar and axillary hyperhidrosis combined. The patients affected by the plantar form were 26 (63%). Clinical follow-up was performed at 3, 6 and 12 months after surgery. Phone interviews and/or clinical assessment were made after a variable period of time (range 6 months to 8 years) to asses long term results., Results: Plantar hyperhidrosis improved in 14 patients, which represents the 54% of the sufferers and the 34% of all patients. It was partially regressed in 11 patients (79%) and resolved in 3 cases (21%). There were not significant differences between patients treated with sympathicotomy and those treated with ganglion block., Conclusions: Transthoracic endoscopic sympathectomy performed through T3-T4 sympathicotomy or ganglion block improves plantar hyperhidrosis in approximately 54% of the affected patients, with a partial and complete resolution rate of 79% and 21% respectively.

Objectives: Thoracic sympathectomy is considered the most effective method to treat palmar hyperhidrosis. We developed a novel approach for thoracic sympathectomy in patients with palmar hyperhidrosis through the umbilicus, using an ultrathin gastroscope. The aim of this study was to evaluate the continuing efficacy and patient satisfaction of this innovative surgery., Methods: All procedures were performed under general anesthesia and the patients were intubated with a dual-lumen endotracheal tube. After a 5-mm umbilical incision, the muscular parts of the diaphragmatic dome were incised with a needle-knife and the nasal gastroscope was advanced into the thoracic cavity. The sympathetic chain was identified at the desired thoracic level and ablated with hot biopsy forceps. All patients were followed up for at least 1 year after the procedure through clinic visits or telephone/e-mail interviews., Results: From April 2010 to August 2011, a total of 35 patients underwent a transumbilical thoracic sympathectomy. Fifty-seven percent were male patients, with a mean age of 21.2 years (range, 16-33 years). The success rate after 12 months was 97.1% (34 of 35) for isolated palmar hyperhidrosis and 72.2% (13 of 18) for axillary hyperhidrosis. Compensatory sweating was reported in 28.6% of patients at the 1-year follow-up evaluation. There was no mortality, no diaphragmatic hernia, and no Horner syndrome was observed. Quality of life related to hyperhidrosis improved substantially in 27 (77.1%) patients, and improved in 4 (11.4%) patients at 12 months after surgery. A total of 94.3% of patients were satisfied with the excellent cosmetic results of the surgical incision., Conclusions: Transumbilical thoracic sympathectomy is an efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paresthesia associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Patients diagnosed with axillary hyperhidrosis can face psychosocial issues that can ultimately hinder their quality of life both privately and socially. The routine treatment for axillary hyperhidrosis is T3-T4 sympathectomy, but compensatory sweating is a serious side effect that is commonly seen with this approach. This study was designed to evaluate whether a T3 sympathectomy was effective for the treatment of axillary hyperhidrosis and whether this treatment led to less compensatory sweating than T3-T4 sympathectomies among our 60-patient population., Methods: One hundred and twenty endoscopic thoracic sympathectomies were performed on 60 patients who had axillary hyperhidrosis. The sympathectomies were accomplished by means of a single-lumen endotracheal tube and a single port. The axillary hyperhidrosis patients were randomly divided into two groups with 17 patients in Group 1 undergoing T3-T4 sympathectomies and 43 in Group 2 undergoing only T3 sympathectomies. We analysed the data associated with the resolution of axillary hyperhidrosis, the degree of patient satisfaction with the surgical outcome and the quality of life in parallel with compensatory sweating after the procedure as reported by the patient and confirmed by the examiner. Moreover, the results were compared statistically., Results: No statistically significant difference was observed between the groups based on age (P=0.56), gender (P=0.81), duration of the surgery (P=0.35) or postoperative satisfaction levels (P=0.45). However, the incidence and degree of compensatory sweating were lower in the T3 group than the T3-T4 group at the 1-year follow-up (P=0.008)., Conclusions: T3 sympathectomy was as effective as T3-T4 sympathectomy for the treatment of axillary hyperhidrosis based on the patients' reported postoperative satisfaction, and the T3 group demonstrated lower compensatory sweating at the 1-year follow-up.

Background: Endoscopic thoracic sympathectomy (ETS) is now an established surgical technique for treatment of palmar hyperhidrosis that is performed under general anesthesia with positive pressure ventilation via either an endotracheal tube or a double lumen endobronchial tube. This is a bilateral disease that requires the division of the right and left thoracic sympathetic chain. The aim of this study was to compare the hemodynamic changes using a left capnothorax first versus right a capnothorax first surgical approach using a single lumen endotracheal tube in patients undergoing bilateral ETS. Lung collapse was achieved by carbon dioxide insufflation., Methods: Forty patients of both sexes aged 18-30 years and of American Society of Anesthesiologists grade I were randomly assigned to undergo bilateral ETS. Patients were divided into two groups. Group L comprised left capnothorax first, followed by right capnothorax (n = 20). Group R comprised right capnothorax first, followed by left capnothorax (n = 20). The anesthesia technique was standardized for all patients. Cardiovascular variables were determined during the procedure every minute. Statistical analysis was performed by independent-sample t test and Pearson's chi-square test., Results: There was a significant (P < 0.05) mean percentage decrease in systolic blood pressure in group L compared to group R. Similarly, the mean percentage decrease in diastolic blood pressure in group L was significant compared to group R (P < 0.05). Seven patients in group L developed bradycardia, but this was not found to be statistically significant., Conclusions: When the left capnothorax first approach was used, there was significant hypotension, compared to a right capnothorax first thoracoscopy. We thus recommend that right capnothorax should be performed first in cases of bilateral ETS.

Introduction: Since the introduction of Endoscopic Thoracic Sympathectomy ( ETS ) by Kux in 1951, the procedure has been performed for treatment of primary hyperhidrosis (PH) of the upper limb. Despite its initial success and minimally invasive nature, the long-term results are yet to be established. The aim of this study is to evaluate the outcome of patients after ETS with particular emphasis on patient satisfaction and its effectiveness over a 16-year period., Methods: A patient survey of fifty-one (n = 51) patients who had ETS for PH of palms from 1995 to 2011 was conducted. The data on age, sex, site of the PH, family history, trigger, hospital stay, relief from symptoms, complications, refractory sweating and overall satisfaction with the procedure was analysed with SAS software version 9.1.3., Conclusion: The mean follow-up was 77 months (range, 6-189 months) with equal gender distribution (n = 24 males Vs n = 27 females) and mean age of 19 (range, 13-64 years). The hereditary prevalence was 55%. Forty-six patients (90.2%) reported an immediate (≤24 h) and four patients (7.8%) reported a delay (>24 h) in relief of symptoms. To the best of our knowledge this is longest duration of follow-up reported in the literature., (Copyright © 2012 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Objectives: Video-assisted thoracoscopic sympathectomy is currently the best treatment for palmar and axillary hyperhidrosis. It can be performed through either one or two stages of surgery. This study aimed to evaluate the operative and postoperative results of two-stage unilateral vs one-stage bilateral thoracoscopic sympathectomy., Methods: From November 1995 to February 2011, 270 patients with severe palmar and/or axillary hyperhidrosis were recruited for this study. One hundred and thirty patients received one-stage bilateral, single-port video-assisted thoracoscopic sympathectomy (one-stage group) and 140, two-stage unilateral, single-port video-assisted thoracoscopic sympathectomy, with a mean time interval of 4 months between the procedures (two-stage group)., Results: The mean postoperative follow-up period was 12.5 (range: 1-24 months). After surgery, hands and axillae of all patients were dry and warm. Sixteen (12%) patients of the one-stage group and 15 (11%) of the two-stage group suffered from mild/moderate pain (P = 0.8482). The mean operative time was 38 ± 5 min in the one-stage group and 39 ± 8 min in the two-stage group (P = 0.199). Pneumothorax occurred in 8 (6%) patients of the one-stage group and in 11 (8%) of the two-stage group. Compensatory sweating occurred in 25 (19%) patients of the one-stage group and in 6 (4%) of the two-stage group (P = 0.0001). No patients developed Horner's syndrome., Conclusions: Both two-stage unilateral and one-stage bilateral single-port video-assisted thoracoscopic sympathectomies are effective, safe and minimally invasive procedures. Two-stage unilateral sympathectomy can be performed with a lower occurrence of compensatory sweating, improving permanently the quality of life in patients with palmar and axillary hyperhidrosis.

Objective: The goal of this retrospective study was to evaluate the outcomes of bilateral video-assisted thoracoscopic sympathectomy for primary hyperhydrosis., Methods: Between January 2007 and December 2011, a total of 335 patients (192 male, 143 female, mean age 28.3 years) who underwent bilateral thoracoscopic sympathectomy for primary hyperhydrosis were reviewed retrospectively., Results: Hyperhydrosis occurred in the palmar and axillary region in 175 (52.23%) patients, in only the palmar region in 52 (15.52%), in the craniofacial region in 44 (13.13%), in only the axillary region in 42 (12.53%), and in the palmar and pedal regions in 22 (6.56%) patients. Bilateral thoracoscopic sympathectomy was performed in all patients. The mean follow-up period was 24 (6-48) months. The initial cure rate was 95% and the initial satisfaction rate was 93%. There was no mortality in this study. The complication rate was 15.82% in 53 patients., Conclusion: Video-assisted thoracoscopic sympathectomy for the treatment of primary hyperhydrosis was effective, with low rates of morbidity and mortality. Despite the appearance of postoperative complications, such as compensatory sweating, patient satisfaction with the procedure was high and their quality of life improved.

Background: Video-assisted thoracoscopic sympathectomy (VATS) is the gold standard for patients with hyperhidrosis of the upper limbs. The primary aim of this retrospective study was to evaluate the midterm outcome and the degree of satisfaction of patients who underwent single-port VATS., Methods: Forty three patients diagnosed with hyperhidrosis underwent T3, T4 VATS single-port approach, between January 2009 and May 2011. Early and midterm outcome with particular emphasis on patient satisfaction were collected by hospital chart and telephonic interview., Results: The mean follow-up was 14 months. No major perioperative complication occurred except for chylothorax in a case. During the immediate postoperative period, all the patients reported palmar anhydrosis. Compensatory sweating (6.9%) and recurrence of hyperhidrosis (6.9%) are responsible mainly for dissatisfaction. No patients experienced moderate or severe chronic pain., Conclusions: Single-port VATS is a feasible and minimally invasive technique with a low incidence of chronic pain for the treatment of hyperhidrosis. A few patients may experience compensatory sweating and recurrence of hyperhidrosis. The degree of patient satisfaction with the midterm surgical results is high., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

A side-effect of endoscopic thoracic sympathectomy (ETS) is compensatory hyperhidrosis (CH), characterized by excessive sweating from skin areas with intact sudomotor function. The physiological mechanism of CH is unknown, but may represent an augmented local sweat rate from skin areas with uninterrupted sympathetic innervation based on evaporative heat balance requirements. For a given combination of activity and climate, the same absolute amount of evaporation (if any) is needed to balance the rate of metabolic heat production both pre- and post-ETS. However, the rate of local sweating per unit of skin surface area with intact sudomotor activity must be greater post-ETS as evaporation must be derived from a smaller skin surface area. Under conditions with high evaporative requirements, greater degradations in sweating efficiency associated with an increased dripping of sweat should also occur post-ETS, further pronouncing the sweat rate required for heat balance. In conclusion, in addition to the potential role of psychological stimuli for increased sudomotor activity, the existence of CH post-ETS can be described by the interplay between fundamental thermoregulatory physiology and altered heat balance biophysics and does not require a postoperative alteration in physiological control.

Objectives: Current data do not provide enough information on how quality of life (QoL) evolves over time in cases of endoscopic thoracic sympathectomy (ETS). The purpose of this study was to ascertain whether the immediate improvement in QoL after the surgery was sustained until the fifth postoperative year., Methods: This was a prospective, nonrandomized and uncontrolled study. From March 2001 to December 2003, 475 consecutive patients with hyperhidrosis submitted to ETS were included. A QoL questionnaire was applied at the preoperative day, around the 30th postoperative day, and after the fifth year., Results: After excluding 22 patients who did not answer all the questions, we analyzed 453 patients. Their ages ranged from 11 to 57 years old, with a mean of 25.3 + 7.9 years, including 297 female patients (65.6%). All patients were assessed on three occasions: before surgery, around the 30th postoperative day, and after the fifth postoperative year. The QoL before surgery was considered to be poor or very poor for all patients. The QoL around 30 days after surgery was better in 412 patients (90.9%), the same in 27 patients (6.0%), and worse in 14 patients (3.1%). After 5 years, 409 patients (90.3%) were better, 27 (6.0%) were the same, and 14 (3.1%) were worse. There were no differences between these postoperative times according to the McNemar statistical test., Conclusion: The patients had an immediate improvement in QoL after ETS, and this improvement was sustained until the fifth postoperative year., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Hyperhidrosis is a disorder of excessive sweating beyond what is expected for thermoregulatory needs and environmental conditions. Primary hyperhidrosis has an estimated prevalence of nearly 3% and is associated with significant medical and psychosocial consequences. Most cases of hyperhidrosis involve areas of high eccrine density, particularly the axillae, palms, and soles, and less often the craniofacial area. Multiple therapies are available for the treatment of hyperhidrosis. Options include topical medications (most commonly aluminum chloride), iontophoresis, botulinum toxin injections, systemic medications (including glycopyrrolate and clonidine), and surgery (most commonly endoscopic thoracic sympathectomy [ETS]). The purpose of this article is to comprehensively review the literature on the subject, with a focus on new and emerging treatment options. Updated therapeutic algorithms are proposed for each commonly affected anatomic site, with practical procedural guidelines. For axillary and palmoplantar hyperhidrosis, topical treatment is recommended as first-line treatment. For axillary hyperhidrosis, botulinum toxin injections are recommended as second-line treatment, oral medications as third-line treatment, local surgery as fourth-line treatment, and ETS as fifth-line treatment. For palmar and plantar hyperhidrosis, we consider a trial of oral medications (glycopyrrolate 1-2 mg once or twice daily preferred to clonidine 0.1 mg twice daily) as second-line therapy due to the low cost, convenience, and emerging literature supporting their excellent safety and reasonable efficacy. Iontophoresis is considered third-line therapy for palmoplantar hyperhidrosis; efficacy is high although so are the initial levels of cost and inconvenience. Botulinum toxin injections are considered fourth-line treatment for palmoplantar hyperhidrosis; efficacy is high though the treatment remains expensive, must be repeated every 3-6 months, and is associated with pain and/or anesthesia-related complications. ETS is a fifth-line option for palmar hyperhidrosis but is not recommended for plantar hyperhidrosis due to anatomic risks. For craniofacial hyperhidrosis, oral medications (either glycopyrrolate or clonidine) are considered first-line therapy. Topical medications or botulinum toxin injections may be useful in some cases and ETS is an option for severe craniofacial hyperhidrosis.

Background: The aim of this study was to compare two different sympathicotomy procedures for primary hyperhidrosis in terms of compensatory sweating, complications, safety and effectiveness., Methods: The data of 78 consecutive patients who underwent bilateral endoscopic thoracic sympathicotomy (156 laterals) for palmar hyperhidrosis between January 2005 and September 2009 were studied retrospectively. The first 29 consecutive patients were treated with a T2-3 sympathicotomy (Group A). After November 2007, all patients (49 patients) were treated with a T3 sympathicotomy alone (Group B). The chest tubes were always removed after checking for pneumothorax with roentgenography. All patients were followed up and evaluated for results, side effects, complications, and satisfaction levels. The differences between the two groups were analyzed., Results: The mean age of the 47 (60.2 %) female and 31 (39.8 %) male patients was 25.2 years. Horner's syndrome and pneumothorax was not detected in either group. The mean follow-up time was 20.82 months (6-52 months). Effectiveness of the procedure at the time of discharge and at follow-up was 100 % and 97.5 %, respectively. There was no significant difference between groups with regard to any analyzed parameter., Conclusion: This study demonstrates that preserving the T2 ganglion is safe, and does not compromise the effectiveness of the procedure. Sympathicotomy has the same success rate as sympathectomy, but requires significantly less dissection and results in less tissue trauma., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Our aim was to establish a standardized approach for patients with palmoplantar and axillary hyperhidrosis and to compare patient satisfaction and complication rates for two different operations., Materials and Methods: Between 2008 and 2010, 30 patients underwent conventional T3/4 clipping (group A), and 30 underwent only T3 and T6 clipping (group B). Both groups were compared with regard to compensatory sweating (CS), complications, patient satisfaction and recovery of plantar hyperhidrosis., Results: The CS rate was 60 % in group A and 47 % in group B. CS was significantly less in group B compared to group A ( P ≤ 0.001). The plantar hyperhidrosis recovery rate was higher in group B (n = 19) compared to group A (n = 13), but the difference was not statistically significant ( P ≥ 0.299). Patient satisfaction rate was 93.3 % in group A and 96.6 % in group B., Conclusions: Our study showed that T3/6 clipping was as effective as T3/4 clipping for palmar and axillary hyperhidrosis. Our results revealed that this technique is more effective than T3/4 sympathectomy to treat plantar hyperhidrosis., (© Georg Thieme Verlag KG Stuttgart · New York.)